VIU (visual internal urethrotomy, also called DVIU) is an endoscopic procedure that cuts a urethral stricture from inside the urinary passage. It has no external incision and recovery is usually quick. However, VIU is not equally effective for all strictures. Current EAU guidance supports it mainly for a primary, single, short (under 2 cm), non-obliterative bulbar stricture. It should not be used as definitive treatment for penile or long-segment strictures. After uncomplicated VIU, the catheter generally does not need to stay for more than 72 hours.

What is VIU surgery?

A cystoscope/urethrotome is passed through the urethra until the stricture is seen. Under direct vision, the scar is incised to widen the lumen. A guidewire is often used to maintain a safe path into the bladder, and a catheter is left temporarily while the cut heals.

Who is a good candidate for VIU?

How is VIU performed?

The procedure is usually done under spinal or general anaesthesia. The narrowing is inspected, a guidewire is passed if possible, and the scar is incised with a cold knife or an energy-based instrument depending on surgeon experience and resources. The aim is to open the scar safely without creating a false passage.

How long does the catheter stay?

For an uncomplicated DVIU, current EAU guidance advises that prolonged catheterisation has no advantage and recommends removal within 72 hours. Individual cases may differ if there is significant bleeding, false passage, infection or another procedure was performed at the same time.

What is normal after VIU?

• Mild burning during urination after catheter removal.
• A small amount of blood in the urine.
• Urgency or frequency for a short period.
• Temporary perineal/urethral discomfort.

What should improve?

The stream often becomes stronger immediately. Improvement can be dramatic because the scar has been opened. The important question is whether that improvement remains durable as the urethra heals over the following months.

Why does VIU recur?

VIU cuts scar but does not remove the biological tendency of the scar to contract. Published patency rates vary widely because outcomes depend heavily on stricture selection. Recurrence commonly occurs within the first year in less favourable disease. Repeating the same procedure indefinitely is unlikely to create a permanent cure.

What if the stricture returns?

A short, veil-like recurrence in selected circumstances may be treated endoscopically again. For recurrent bulbar disease after failed endoscopic treatment, urethroplasty generally offers greater durability. Penile, long or complex strictures should be considered reconstructive problems rather than repeated-VIU problems.

VIU versus urethroplasty

VIU has the advantage of being short, minimally invasive and easy to recover from. Urethroplasty is a larger operation with a perineal or penile incision and longer catheterisation, but it offers a higher chance of long-term patency for recurrent or complex strictures. The correct comparison is therefore not “small surgery versus big surgery” but “which procedure fits this stricture anatomy.”

What determines whether VIU is likely to last

VIU works by cutting through scar tissue so the urethral lumen can widen while the incision heals. It does not remove the biological tendency of that scar to contract again. This explains why patient selection is more important than the instrument used.

The best-supported setting is a primary, single, short (under about 2 cm), non-obliterative bulbar stricture. Outcomes fall as strictures become longer, recurrent, penile or densely fibrotic. The 2026 EAU guideline specifically advises against DVIU for penile strictures and against using DVIU/dilatation alone for long (>2 cm) strictures. Laser or “hot knife” techniques have not consistently shown superior long-term durability over cold-knife incision.

After VIU, intermittent self-dilatation may reduce or delay recurrence in selected patients, but that is better described as stabilising the lumen than guaranteeing a cure. If a stricture repeatedly returns, the discussion should move from “how do we open it again?” to “what is the durable reconstructive option, and is the patient a suitable candidate?”

What happens on the day of VIU and afterwards

VIU is performed through a cystoscope or urethrotome passed through the natural urinary passage. Under anaesthesia, the narrowing is visualised and incised until an adequate lumen is obtained; a guidewire may be used to maintain the correct path in difficult anatomy. The bladder can be inspected when appropriate and a urethral catheter is left across the treated segment.

Hospital stay is commonly short, often day-care or overnight depending on anaesthesia, bleeding, infection risk and comorbidity. Mild burning, frequency and blood-tinged urine can occur after catheter removal. Heavy bleeding, fever, inability to void or worsening suprapubic pain are not routine recovery symptoms.

Follow-up matters because immediate symptomatic improvement does not predict long-term durability. Uroflowmetry several weeks or months later provides a new baseline. A progressively flattening curve or recurrent straining should prompt reassessment before the patient reaches complete retention.

Why recurrence after VIU is not a technical surprise

VIU creates a controlled incision through scar but does not replace diseased urethral tissue with healthy tissue. The cut heals by secondary intention, and that healing can contract again. This biology explains why outcome depends strongly on stricture selection rather than simply on how widely the scar was cut on the day of surgery.

The best endoscopic candidates are generally first-time, short, non-obliterative bulbar strictures. Long, penile, multiple or repeatedly recurrent strictures behave less favourably. Current EAU guidance specifically advises against DVIU for penile strictures and against using DVIU/dilatation alone for long strictures, and discourages repeated endoscopic treatment when urethroplasty is a viable alternative.

Intermittent self-dilatation may be used in selected patients to stabilise rather than cure recurrent disease. It is not equivalent to a durable anatomical reconstruction and should be discussed with a clear goal and stopping plan.

Follow-up

Flow symptoms should be reassessed after the procedure. Uroflowmetry is useful to establish a new baseline. If the stream again becomes weak or plateau-shaped, RGU or cystoscopy may be needed before deciding the next treatment.

What to bring for consultation if VIU has failed

• RGU and MCU/VCUG images or films, not only the written report.
• Uroflowmetry report and post-void residual if already done.
• Urine routine and urine culture reports.
• Serum creatinine and other relevant blood tests.
• Previous catheter, VIU/dilatation or urethroplasty discharge summaries.
• Details of any pelvic injury, prostate surgery, hypospadias surgery, radiation or recurrent infections.
• Current medicines, including blood thinners, and any history of self-dilatation.

FAQs

Related reading

• VIU vs Urethroplasty: Which Is Better?
• Failed VIU: What Next?
• Urethroplasty Surgery Explained
• Uroflowmetry in Urethral Stricture
• Recurrent Urethral Stricture: Why It Comes Back
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males
• European Association of Urology. EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery
• European Association of Urology. EAU Guidelines on Urethral Strictures: Follow-up, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/followup
• American Urological Association. Urethral Stricture Guideline (2023 amendment) https://www.auanet.org/guidelines-and-quality/guidelines/urethral-stricture-guideline
• European Association of Urology. EAU Guidelines on Urethral Strictures, 2026 https://uroweb.org/guidelines/urethral-strictures